Posts Tagged ‘NSAIDs’

The doctor takes the wrong end of the scalpel

March 4, 2013

In the head there’s this thing called a brain.

Where we feel our pride and our pain

But when the cutting is done

Are narcotics just fun?

Or the source of some ill-gotten gain?

Synopsis:  I’m a family practitioner from Sioux City, Iowa.  In May 2010, I left my position of 23 years, and honoring my non-compete clause, traveled for a year doing locum tenens work.  In June of 2011 I joined up with the Community Health Center, which provides care for the underserved.  I’m now working part-time, which, for a doctor, means 54 hours a week.

Recovering from surgery cuts into the desire to write, but I’m doing better now.

Even doctors must have doctors; the internal dialogue that leads us to minimize contact with our own profession has gradually led us to healthier life styles.  Few doctors smoke in the 21st century; most of us exercise regularly.  While no doctor should prescribe for him or herself, neither should any patient completely abrogate self-advocacy nor decision-making. 

I won’t dwell on the circumstances that led me to a repeat surgery; denial worked for a long time but eventually failed.  Thus on Valentine’s Day I sat in our local specialized surgical center, hungry and thirsty waiting for anesthesia.

The procedure started on time, but went long, only because of the nature of the problem.

A lightweight when it comes to most medications, I dozed off and on for the rest of the day.  When it came time to leave, I adamantly refused a prescription for a popular narcotic.  The exchange with the nurse went several rounds and finished with her tearing the slip to bits and putting it in a small plastic envelope designated for that purpose.

All narcotics slow the gut and suppress the cough reflex.  I feared constipation (after a major abdominal procedure) and pneumonia more than I feared pain.   Nor would my marginal kidney function permit me the usual pain relief of the NSAIDs (a drug class that includes Ibuprofen, Alleve, Toradol, diclofenac, and 28 others).

Which left humble acetaminophen, also known as Tylenol.

If we assign post-operative pain a range of 1 to 10, we know that the much-abused oral opiates like Percodan and Norco can bring the pain down by 2.7 points in the same study where an inactive pill will bring it down by 2 points and Tylenol by 2.1 points.

(Interestingly, propoxyphene, the active ingredient in Darvon, now removed from the market, would decrease it by 1.7, which means that despite bringing euphoria, a drug could aggravate acute pain; a phenomenon we see with marijuana and chronic pain.)

I have spent most of the last 5 days asleep, but today I’m coming around.  My appetite and my sense of humor have palpably improved through the day.  I still fear coughing but I do it anyway. 

I didn’t actually need the narcotics.

When I talk to my non-drug abusing patients after a surgery, most of them didn’t, either.


Changing the diagnosis in the face of change: against complacency

January 23, 2011

I took a good look at the hand

I kept an expression so bland

     without honest guide,

     You can run but not hide

Just keep your head out of the sand

Synopsis: I’m a family practitioner from Sioux City, Iowa.  Transitioning my career away from the brink o f burnout, I’m taking a sabbatical while my one-year non-compete clause expires.  I’m having adventures, visiting family and friends, and working in out-of-the-way places.  Currently I’m in Barrow, Alaska, the northernmost point in the United States.

I took care of a patient who has given me permission to write the following information.

Hand pain, concentrated at the joints where the fingers meet the hands and the knuckles closest to those, and pain in the wrists, brought her in to see the docs here in the fall.  Concerned about some abnormal blood work, they requested a rheumatology consultation.  The rheumatologist diagnosed osteoarthritis and prescribed non-steroidal anti-inflammatory drugs (NSAIDs).  Osteoarthritis comes from wear and tear on the joints.  In the hands, it characteristically affects the knuckles closest to the nails.  It has nothing to do with rheumatoid arthritis, a disease which scourges the entire body.  Treatments for the two diseases differ vastly.  NSAIDs comprise the mainstay of osteoarthritis therapy, the powerful drugs which modulate the immune system in rheumatoid arthritis have no place in osteoarthritis.

The patient got steadily worse.  She now has severe morning stiffness, pain that wakes her up at night, and worse pain than ever in more joints than before, now including her shoulders and knees.

As soon as I walked in the room, I saw that the fingers of her right hand were swollen in a fashion that gives rise to the term “sausage fingers.”

While I’m checking for other diagnoses, I’m fairly confident she has rheumatoid arthritis.  Her x-rays, normal in December, confirm the joint erosion and bone thinning near the joint, typical of the disease.

Like every patient, she lives in a social, family, and community context.  Whatever her diagnosis, the course of her illness will touch everyone she knows in an unpredictable fashion.

My sensitivity to the rheumatologic diseases stems from my own ankylosing spondylitis, and my experience with the medical profession misdiagnosing me for seventeen years (which was the best thing they could have done for me at the time; the rudimentary treatments back then weren’t much better than the disease).

I know when I don’t know and when I don’t know I know what to do: call someone who knows more than I do.

Humans tend to complacency.  I had the urge to accept the diagnosis of osteoarthritis, because I regard the rheumatologist as having expertise in the area.  But in the end, I just couldn’t make the patient’s history and the physical findings fit.  Even if the patient had osteoarthritis in December, she doesn’t have it now.

  Patient conditions change, world conditions change, and without the ability to adapt, survival becomes problematic.